State allows some doctors to prescribe drugs even after they're charged with crimes

State health officials declared Dr. Mark Kantzler unfit to practice medicine because of drug abuse and, fearing for his patients' safety, suspended his license by emergency order in July 1991.

Today, the family practitioner runs a St. Petersburg area pain clinic . He is among Florida's top prescribers of narcotics to low-income people -- $419,751 worth in the past three years. During that time, eight of his patients have died of drug overdoses.

A South Florida Sun-Sentinel investigation found dozens of doctors allowed to continue freely prescribing dangerous drugs at state expense, even after multiple patients have died of an overdose, and even in extreme cases where they have been charged with drug crimes or serious misconduct. The state has no system that monitors, sounds an alarm or stops doctors who abuse the system.

The investigation found:

As a group, the doctors who prescribe the most narcotics to Medicaid patients are 10 times more likely to have troubled professional histories than doctors overall in the state.

State officials have disciplined or charged 10 of the top 200 Medicaid-prescribing doctors for abusing drugs, trading pills for sex with patients, or recklessly handing out prescriptions. At least another 15 have faced criminal charges ranging from insurance billing fraud to drug trafficking, or have been accused by state regulators of incompetence or misconduct.

Doctors who prescribed the costliest volumes of drugs have some of the shakiest practice records. And doctors who prescribe the largest amounts of OxyContin, an often-abused painkiller, have the highest rate of disciplinary problems.

Seven of 16 doctors who each wrote more than $1 million worth of narcotics prescriptions had professional misconduct charges or criminal arrests in their pasts, including two doctors arrested for narcotics trafficking. Nine of 29 doctors who ordered OxyContin for 100 or more Medicaid patients last year had serious disciplinary action or arrests in their pasts.

No state agency has set up a system to monitor the practices of troubled doctors whose patients wind up dying of pill overdoses. Even when investigations have been opened, they took years to complete and the doctors continued to see patients and to hand out prescriptions.

No alerts in place
The Sun-Sentinel traced hundreds of overdose deaths through autopsy records collected from Florida's two dozen medical examiners and through pharmacy billing data to many of the top Medicaid-prescribing doctors.

In some cases, doctors who dramatically increased the number of those prescriptions experienced a rash of deaths among their patients. State officials concede that they have no system that alerts them to spikes in a doctor's Medicaid billings for narcotics or to numerous deaths among a doctor's patients.

Medicaid's costs for Kantzler's prescriptions nearly doubled in 2001 and into 2002, when he wrote more controlled-drug orders than all but 79 of almost 57,000 Florida medical professionals.

During that time, six of his patients died of overdoses.

Two men in their late 40s died in March 2001, one from codeine and the other from the painkiller hydrocodone and a muscle relaxant, records show. In August of that year, a man died of "acute hydrocodone toxicity" a day after he filled a prescription for the drug from Kantzler. Then, in December, a 42-year-old female patient mixed pills with cocaine and died, autopsy records show.

Kantzler's personal problems with drugs go back a decade.

Starting in late 1989, he spent six months hospitalized in a rehabilitation program for drug abuse. About a year later, a urine screen found Nubain, a morphine-like drug, in his system, and the state suspended his license.

Florida's Board of Osteopathic Medicine gave it back two months later after a psychologist said Kantzler could safely return to practice as long as he kept up counseling and submitted to random urine screens.

Kantzler, without admitting he did anything wrong, agreed to pay a $2,500 fine and complete a course of drug rehabilitation. He could not be reached for comment for this story after repeated phone calls and a letter sent to his office. Kantzler is one of a small number of doctors who stand out for writing high volumes of prescriptions, according to the newspaper's analysis of Medicaid billing records.

Of all the medical professionals in Florida, only 200 prescribed more than $215,000 worth of painkillers and other controlled drugs through Medicaid in the past three years.

While about 3 percent of the state's doctors have been disciplined for misconduct, such sanctions were 10 times more common among the top narcotics-prescribing doctors.

State officials don't routinely monitor Medicaid pharmacy billings or autopsy reports to guard against doctors or pharmacists who may be endangering patients, or ripping off taxpayers, by oversupplying drugs.

Instead, doctors are disciplined through a cumbersome process that typically takes two years or more. It begins after a patient or other aggrieved party files a written complaint with the state. The state then assigns experts to decide whether the care provided fell below standards. The doctor can contest these findings and keep on practicing while problems remain shielded from the public.

The Department of Health can suspend a doctor's license by emergency order to protect the public while it investigates a doctor, but it has done so in only 12 cases since September of 2001. Four of those actions came in response to Sun-Sentinel articles tying the doctors to multiple overdose deaths.

Pill-pushing allegations can take even longer to sort out because Florida law requires doctors to treat pain aggressively, and many experts disagree about the proper limits for dosages of narcotics.

Doctors are expected to keep persuasive evidence of the need for these drugs, such as diagnostic tests that confirm injuries, and to document their patients' improved ability to function as a result of taking the drugs over time.

Those who deviate from these standards without "good cause" can be disciplined, according to the Florida Board of Medicine, which also warns in guidelines that doctors will be judged "to a great extent by the treatment outcome."

Death from overdose as an outcome of treatment has mostly escaped the attention of state regulators.

The 16 doctors who each generated $1million or more in narcotics billings to Medicaid illustrate the situation.

Deaths documented
The newspaper documented 61 deaths from overdoses for people under the care of these doctors, most in the past two years.

Three of the million-dollar prescribers have been arrested in recent years, two on drug trafficking charges. One, Dr. Asuncion Luyao of Port St. Lucie, was suspended from practicing medicine in Florida as a result. She also faces trial early next year on manslaughter charges.

One doctor the newspaper investigated, Jayam Krishna-Iyer, stayed on track in her career despite an arrest for illegal distribution of prescription drugs in 2000.

Federal agents set their sights on the Clearwater pain specialist because they thought she gave out drugs "without a legitimate medical purpose."

Their undercover investigation ended in June 2000 when a federal grand jury in Tampa indicted the anesthesiologist on drug trafficking charges. In court filings, prosecutors alleged she accepted $175 in cash for prescribing narcotics to undercover drug agents whom she did not examine or run any medical tests on.

Prosecutors dismissed the charges after Krishna-Iyer agreed to take a week of courses in medical ethics and pain management and pay another doctor to supervise her pain-care practice for one year.

Medicaid has paid more than $1.6 million for narcotics Krishna-Iyer ordered during the past three years, when at least 10 of her patients died of overdoses, the newspaper found.

Medicaid paid another doctor $3.9 million for her to see patients and for other services for patients over four years, from 1998 through 2001, the Sun-Sentinel found. Dr. Shelley Wolland, an osteopathic physician who lived in Davie, got into trouble in November 2001 when a surprise state inspection found she was stocking outdated, possibly adulterated, injectible AIDS drugs at Sunshine Medical, a clinic she owned in Miami. The state osteopathic board in March 2002 prohibited her from dispensing or injecting any medication.

About two months later, investigators arrested her on charges of cheating Medicaid out of more than $400,000 by filing phony claims for services. Neither her arrest nor the board's disciplinary action restricted her from writing prescriptions for narcotics -- which she had done in huge volume.

Medicaid paid $1.5 million for narcotics and other controlled drugs billed in Wolland's name, the 10th highest among doctors in the state, during the past three years, billing records show.

The newspaper could not reach the doctor for comment. Her lawyer did not return repeated phone calls and her clinic is apparently closed.

The newspaper found that out of the top dozen narcotics prescribers, only Dr. Barry Rodwick had not at some time been charged with or disciplined for professional misconduct or faced criminal charges or had claims for payment flagged by state officials.

Many other doctors under state investigation for errant prescription writing, or personal drug abuse, had patients die of drug overdoses either while the disciplinary process lumbered along, or after a sanction was imposed.

Five had difficulties
In the Sarasota area, five of the 29 doctors the newspaper linked to overdose deaths have been in trouble with the state.

Dr. West Magnon, a 79-year-old Bradenton psychiatrist with a history of alcohol and drug abuse, was one.

In March 2002, a pharmacist reported to the state that Magnon had written "suspicious prescriptions." Officials ordered the doctor to undergo a urine test, which disclosed a sedative in his system.

Also that month, one of Magnon's patients, a 34-year-old Bradenton woman with a history of drug abuse and back pain from arthritis, died on her living room floor of an overdose of pills. Her last appointment with Magnon was two days before, records show.

Magnon also had treated a 44-year-old woman who lived in Palmetto for migraines. The woman died in November 2001, after mixing three drugs Magnon prescribed, including the painkiller oxycodone, with cocaine, autopsy records show.

Despite evidence that the doctor was drug impaired, state officials took until April 24 of this year to suspend his license to practice medicine. The Florida Board of Medicine granted his request to be reinstated in October. He remains on probation.

The doctor could not be reached for comment in repeated calls to his office.

In several other cases, the newspaper found that happenstance, not an aggressive surveillance system, led to doctors being weeded out of the profession.

Such was the case with Dr. Steven Everett, a former Port St. Lucie pain doctor whose career ended as a result of a disastrous affair with a 36-year-old patient turned employee. In October 1999 Everett hired the woman, whom he had treated for a year for muscle spasms and lower back pain, as a respiratory therapist. Within four months they were involved sexually, and a few months after that she was pregnant and saying the baby was his. She miscarried, but during their affair Everett wrote her a prescription for injectable Demerol, a potent narcotic, that he billed to another patient with insurance.

The scheme came to light in May 2000 when his lover landed in jail on charges of unauthorized use of a controlled substance. More than a year later, in July of 2001, the state medical board filed a civil complaint accusing Everett of engaging a patient in sexual activity and committing fraud in the practice of medicine.

Everett didn't show up to contest the charges before the medical board in October 2001. The board revoked his license.

But in the months before the state filed its case, two of Everett's patients, both disabled, died of drug overdoses, according to autopsy reports.

The first was a 30-year-old Jensen Beach woman whom he began treating in February 1999 for what medical records describe as "a constant, aching, burning, shooting sensation that is associated with muscle spasms in the right hip and buttocks." The woman said the pain came on a day after she had done some heavy lifting.

Everett put the woman on OxyContin and kept her on it until May 2001 when she died in her bathroom of an overdose of oxycodone, the drug in OxyContin, three days after filling her prescription.

A month later, the second patient, William Wright, died. He was 43 and had been under the doctor's care just under two years. Everett prescribed 100 injectable Demerol doses, 360 Dilaudid, and 200 pills of methadone, all potent narcotics, in the month before the man's death, medical records show. Everett also had ordered the sedative Valium for the man, who he said in his medical chart would "never be able to work again," and require "potent pain meds and management for a lifetime." The man died of an overdose of methadone and the sedative, an autopsy found.

Some of the doctors who had patients die significantly stepped up their drug prescriptions -- in a few cases by 10 times or more in a single year -- but state officials don't routinely monitor billings so they never noticed.

No case illustrates the pattern of patient deaths after a spike in prescriptions more starkly than that of Jerome Waters. The 74-year-old family doctor practices from a stucco house he owns near downtown Miami, where, he told a reporter, he had built a "reputation" for catering to pill users.

In 2000, Waters prescribed $65,000 worth of OxyContin. By 2002 he was prescribing almost $1 million worth, earning him a spot as the fourth-highest Medicaid prescriber of the drug in the state.

Need for review
"When you see a growth of geometric proportions in drug billings, that should be an indicator that the medical practice needs to be reviewed, said Florida drug czar James McDonough. "The data should not be ignored."

They were ignored.

By reviewing autopsy case filings at morgues in Miami and Fort Lauderdale, the Sun-Sentinel uncovered six deaths among Waters' patients from 2000 through the end of 2002, four involving either methadone or OxyContin. That prompted state health officials to begin an investigation last fall.

But it took until early May this year for them to file an emergency order prohibiting Waters from prescribing narcotics. Nine days after state officials restricted the doctor's practice, another patient died of an overdose, autopsy reports show.

Mitchell Ocana, a 31-year-old Miami Beach actor with a drug abuse problem, didn't call his mother on Mother's Day. She began to worry about her son and called police. They knocked down his door and discovered his body on the bed alongside a crack pipe. Police also found a bottle of morphine pills that Waters had ordered.

Ocana had the prescription filled on May 2, three days before the state order against his doctor.

Fred Schulte can be reached at fschulte@sun-sentinel.com or 954-356-4591.